| Doctor Name: | MR. TIMOTHY THOMAS WALLACE |
| NPI Number: | 1003072414 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | RN |
| License Number: | RN295020 |
| Business Practice Address: | 10000 Brecksville Rd Brecksville, OH - 441413204 |
| Business Phone Number: | 4405263030 |
| Business Fax Number: | |
| Mailing Address: | 10000 Brecksville Rd, BRECKSVILLE |
| State: | OH |
| Postal Code: | 441413204 |
| Phone Number: | 4405263030 |
| Fax Number: | |
| NPI Enumeration Date: | 08/05/2008 |
| NPI Last Update Date: | 08/05/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 163WP0808X |
| License Number: | RN295020 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OH |
| Taxonomy Type: | Nursing Service Providers |
| Taxonomy Classification: | Registered Nurse |
| Taxonomy Specialization: | Psych/Mental Health |
| Taxonomy Definition: | |